醫師臨床經驗對住院醫療品質的影響

Abstract

研究背景：臨床經驗與醫療品質之間的關係，長久以來一直未有明確定論。許多年前國外的研究顯示，年輕醫師因為具有較新穎的醫學知識與技術，較能提供符合實證醫學根據的醫療服務，也有較好的醫療品質。然而，台灣近二十年來，由於執業醫師繼續教育的強制推行，使資深醫師也可以吸取最新的醫學新知。加上資深醫師多年的行醫經驗，其所提供的醫療服務品質，或許已較數十年前有所不同。 計劃目標：本次實務實習的單位是一所位於台北市的公立區域教學醫院，而此次實務研究的目標即以此醫院為例，探討該醫院中不同臨床經驗的主治醫師，所提供的住院醫療服務品質是否有所不同。然而醫療品質有許多面向，本實務研究是以探討結果面指標為主，也是目前評估醫療品質最常用的指標。 研究方法：本研究為先選定特定期間(即西元2013一月一日至西元2013年六月三十日間出院的住院患者)及特定疾病(即：泌尿道感染、肺炎與急性呼吸衰竭三項疾病)，分別將罹患這些疾病的患者，依負責他們住院醫療的主治醫師資歷分成三組，再比較各組住院死亡率、十四日內再住院率、住院天數與住院費用(即醫療品質結果面指標)的差異。另外，再將醫師其他特質也列入考慮，探討這些特質是否與醫療結果面品質指標相關。而各項特質間可能有互相影響的情形，因此最後再以住院死亡人數為例，將所有可能因素納入回歸模式分析，探討醫師臨床經驗是否為醫療品質結果面指標的獨立影響因子。 研究結果：共937個病例列入分析，結果顯示資深主治醫師所照顧的病患，有較低的死亡率(p = 0.001)、較少的住院費用(p < 0.001)，而年輕主治醫師所照護的病患，其住院天數明顯高於中年與資深主治醫師(p = 0.001)。再依疾病嚴重度來看，在輕度嚴重度疾病方面，三組病患結果面指標並無明顯差異，反而是在重度嚴重度疾病方面，年輕主治醫師所照護的病患有較高的醫療費用(p = 0.022)與較長的住院天數(p = 0.035)。在醫師特質方面，雖然內科系醫師與重症專科醫師在醫療品質結果面指標上，表現得較不如外科系醫師與非重症專科醫師，非擔任主管醫師在部份指標上也表現得不如有擔任主管的醫師。然而，不同特質的醫師所照護的病患，其疾病嚴重度可能有所不同。因此將病患年齡、疾病嚴重度等可能影響病患預後的因素一併納入考量後，則不同特質的醫師在醫療品質表現上，並無顯著不同。而資深醫師相對於中年醫師而言，仍有較少的住院死亡人數。因此推論，醫師臨床經驗，仍舊對於醫療品質的結果面指標有重要的影響。 結論：台灣在經過近二十年的執業醫師繼續教育制度後，資深主治醫師的臨床照護品質已有顯著提升。尤其在重度疾病方面，藉由專業知識的不斷更新，搭配豐富的臨床經驗，其醫療品質甚至超越年輕主治醫師。在公共衛生政策方面而言，藉由醫學教育制度的變革、醫師繼續教育的實施，才能確保每位臨床醫師都能擁有最新的醫療知識與技術，社會整體的醫療品質也才能不斷進步。

Background: The relationship between clinical experience and quality of care was not very clear in the past. Several studies for years ago showed that young physician provided medical service more compatible with clinical evidence due to having update medical knowledge and technology, and therefore provided better quality of care. However, the continued medical education has been carried out in Taiwan for about 20 years, and the senior physicians also could get the update medical knowledge and technology. In addition, the senior physician have more clinical experience then young physician, so the quality of care provided by senior physician maybe different from that decades ago. Aim of study: This practicum program was carried out at one municipal, regional teaching hospital in Taipei City of Taiwan. The aim of this study is to find the difference between the quality of in-hospital care provided by physician with different clinical experience in this hospital. However, there are many kinds of indicators about quality of care. Our study is focus on outcome indicators, which are most often being used to evaluate the quality of care in recent years. Methods: In-hospital patient in specific duration (ex: discharged between January 1st, 2013 to June 30th, 2013) with specific disease (ex: pneumonia, urinary tract infection and acute respiratory failure) were selected in this study. These patients were divided into groups according to the clinical experience of their physicians, and then compare the in-hospital death, re-admission in 14 days, hospital days and cost between these groups. The characteristics of physicians were also taken into consideration, and the relationship between these characteristics and outcome indicators was also discussed. Because these characteristics may confound the result, we took in-hospital death as an example, and used binary Logistic regression method to clarify whether clinical experience is an independent factor of in-hospital death. Result: There were 937 cases included in the study, and the analysis result showed patients cared by senior physicians had lower in-hospital mortality (p value = 0.001), fewer costs (p value < 0.001), and patients cared by young physicians had longer hospital days than mid-aged and senior physicians (p value = 0.001). There was no obvious difference between outcome indicators of disease with mild and moderate severity. The patients with high-severity disease cared by young physicians had longer hospital days (p value = 0.035) and higher costs (p value = 0.022). The outcome indicators of internist, physicians with critical medicine, and non-director were more poor. However, physicians with different characteristics may care patient with different severity of disease. If the disease severity and patient's age were all taken into consideration, these physician characteristics didn't showed obvious impact on outcome indicators according multivariate analysis. But the patients cared by senior physicians still have lower in-hospital deaths. So clinical experience still have important impact on outcome indicators of quality of care. Conclusion: The quality of care provided by senior physicians improved during recent 20 years in Taiwan after continued medical education was carried out. Their quality of care in disease of higher severity was better than young physicians due to their good clinical experience and update knowledge. For public health issue, reform of medical education and execution of continued medical education will push every physician to get update knowledge and technology, and therefore the quality of care will improve gradually in the society.